Alessandro Arena

Severe ureteral endometriosis: frequency and risk factors

Abstract Ureteral endometriosis (UE) can be classified as severe when there is obstruction to urinary flow (ureteral compression (UC)). In this retrospective study on 205 patients, we evaluated intraoperatively the frequency of severe ureteral endometriosis (UE) in women with UE and, secondarily, risk factors associated with UC. We documented intraoperatively ureteral UC in 124 (60.5%) patients with UE. A significantly lower body mass index (BMI) was observed in women with UC than in women without UC (p = .02). A significant association was found between UC and parametrial endometriosis (p = .001). In multivariable analysis, these variables remained significantly associated with UC. Ureteral compression is common in patients with UE, especially in women with parametrial infiltration and a low BMI.

Can In-Bag Manual Morcellation Represent an Alternative to Uncontained Power Morcellation in Laparoscopic Myomectomy A Randomized Controlled Trial

Aims: The study aimed to evaluate feasibility and safety of in-bag manual morcellation compared to uncontained power morcellation during laparoscopic myomectomy. Methods: A total of 72 women undergoing laparoscopic myomectomy were randomized into 2 treatment groups: 34 patients underwent in-bag manual morcellation (experimental group) and 38 were submitted to uncontained power morcellation (control group). The primary end point was the comparison of morcellation operative time (MOT). Total operative time (TOT), rate of intraoperative complication, and postoperative outcomes in the 2 groups were regarded as secondary outcomes. Results: Mean MOT and TOT were longer in the experimental group than in the control one (MOT: 9.47 ± 5.05 vs. 6.16 ± 7.73 min; p = 0.01; TOT: 113.24 ± 28.12 vs. 96.74 ± 33.51 min; p = 0.01). No intraoperative complications occurred in either group and no cases of bag disruption or laparotomic conversion were recorded. No significant difference in hemoglobin drop, hospital stay, and postoperative outcomes was reported between groups. Conclusion: In-bag manual morcellation appears a safe and feasible procedure and, despite slightly longer operative time, could represent an alternative to uncontained power morcellation.

Pelvic floor muscle assessment at 3-and 4-dimensional transperineal ultrasound in women with endometriosis, with or without retroperitoneal infiltration: a step towards complete functional assessment

Previous studies comparing women with deep infiltrating endometriosis (DIE) and healthy controls have underlined an association between pelvic floor muscle (PFM) hypertonic dysfunction and deep lesions. The aim of this study was to compare the morphometry of PFM in women affected by ovarian endometriosis with DIE vs those without DIE in order to assess the impact of retroperitoneal infiltration by the disease on PFM function.

Short-term histopathological effects of dienogest therapy on ovarian endometriomas: in vivo, nonrandomized, controlled trial

Abstract Ovarian endometriosis is a common gynecological disorder. To date, progestins are recommended as the first-line medical treatment for symptomatic ovarian endometriosis. The aim of this study was to evaluate the main histopathological effects of short-term dienogest therapy in patients with ovarian endometriomas scheduled for surgery. A prospective, nonrandomized controlled trial, including 70 symptomatic women with single ovarian endometriotic cyst (diameter between 30–50 mm) was conducted. Women scheduled for surgery were divided into two groups, depending on the treatment established at enrollment: 36 women received progestin therapy with dienogest (P group) and 34 women received no therapy (C group). At histopathological examination necrosis, inflammation, decidualization, glandular atrophy and angiogenesis were blindly evaluated. At tissue level, decidualization was significantly more frequent in P group compared to C group (p = .001). A nonsignificant tendency (p = .29) towards a slight decreased inflammation in P group was found. No significant differences were observed between the two groups in terms of necrosis, glandular atrophy and angiogenesis. The study suggests that high decidualization rate and the tendency to reduced inflammatory reaction in the short-term administration of dienogest might contribute to its therapeutic efficacy.

Clinical use of endovenous indocyanine green during rectosigmoid segmental resection for endometriosis

OBJECTIVE To describe a new use of endovenous indocyanine green (ICG) to allow real-time visualization of bowel perfusion in women with recto-sigmoid endometriosis who may be candidates for segmental resection. DESIGN Step-by-step explanation of this method using descriptive text and educational video. SETTING Tertiary level referral academic center. PATIENT(S) A nulliparous 36-year-old woman affected by a large rectal endometriotic nodule was referred for severe dysmenorrhea, dyspareunia, hematochezia, and dyschezia, despite progestinic therapy. INTERVENTION(S) An intravenous injection of 1.5 mL solution containing 3.75 mg dose of ICG for intraoperative fluorescence imaging. MAIN OUTCOME MEASURE(S) Evaluation of blood perfusion of bowel and rectal endometriosis nodule. Evaluation of neoanastomosis vascularization after bowel resection. RESULT(S) The procedure of endometriosis removal was performed using the daVinciXi surgical platform (Intuitive Surgical, Sunnyvale, CA). After ovarian endometriosis removal and adhesiolysis, we identified the endometriosis nodule on the anterior surface of the rectum. Pararectal, rectovaginal, and retrorectal spaces were dissected with a nerve-sparing technique. Indocyanine green was administered through a peripheral line. A near-infrared camera head enabled vision of the colorant after latency of a few seconds. We observed the ischemic area around the rectal nodule and perfusion areas upstream and downstream from the lesion. We selected the transecting line for rectal resection, taking account of this objective evaluation, beyond the limits of macroscopic disease. After direct mechanical anastomosis, we checked the rectal vascularization with ICG. CONCLUSION(S) To the best of our knowledge, this is the first reported use of endovenous ICG during a bowel resection for deep endometriosis. Endovenous ICG is proposed during surgery for rectosigmoid endometriosis to assess the perfusion of the bowel and select the transecting line. With ICG fluorescence imaging, we can objectively evaluate whether blood supply to the anastomosis is adequate. Endovenous ICG for objective vascular assessment is simple and rapid to use, and no complications related to ICG use were recorded.

Transvaginal and transperineal ultrasound follow‐up after laparoscopic correction of uterine retrodisplacement in women with posterior deep infiltrating endometriosis

Retrodisplacement of the uterus (retroflexion and/or retroversion) may be associated with pelvic pain symptoms and posterior deep infiltrating endometriosis (DIE). Previous studies in symptomatic women with retrodisplacement of the uterus showed the efficacy of hysteropexy in terms of pain symptoms improvement.

OP31.03: Pelvic floor morphometry at three- and four-dimensional transperineal ultrasound in women with ovarian endometriosis or deep infiltrating endometriosis

Objectives: To assess the changes in the volume of endometriomas and rectovaginal endometriotic nodules (RVE) during 12-month treatment with norethindrone acetate (NETA) versus extended-cycle oral contraceptive. Methods: This patient preference prospective study included women of reproductive age with endometriosis. Patients received either continuous oral treatment with NETA (2.5 mg/day, Primolut-Nor® Schering, Milan, Italy; group A) or a 91-day extended-cycle oral contraceptive (LNG/EE 150/30 mcg for 84 days and EE 10 mcg for 7 days, Seasonique® Teva, Assago, Italy; group B) for 12 months. The volume of the lesions was assessed by virtual organ computer-aided analysis (VOCAL, GE Healthcare, USA). The changes in the volume of endometriomas and RVE were compared between baseline, after 6 and 12 months of treatment. The echogenicity of the endometriomas was subjectively evaluated by the ultrasonographer using a Likert scale. Results: 100 patients were enrolled in the study (50 in each group). 45 patients completed the treatment in group A and 38 in group B. In both study groups, the volume of the cysts significantly decreased at 6 (p<0.05) and 12 months of treatment (p<0.05; percentage reduction: 56.5% in group A and 55.7% in group B) compared with baseline. The decrease in the volume of the cyst between 6-month and 12-month treatment reached statistical significance in both study groups (p < 0.05). After 12 months of treatment, the echogenicity of the endometriomas significantly changed in both study groups (p<0.05). After 6 and 12 months of treatment, the volume of the RVE significantly decreased in both groups compared to baseline. There was a significant reduction in the volume of the RVE between the 6 and 12 months of treatment (p<0.05 for both study groups). Conclusions: Both NETA and Seasonique® are effective in reducing the volume of the endometriomas and RVE.